Perianal Giant Condyloma Acuminatum with HIV

Treated with Surgical Excision

Irvin Aldikha

, Rr. Widya Kusumaningsih

, Asih Budiastuti

, Muslimin

Meira Dewi Kusuma Astuti

Department of Dermatovenereology, Medical Faculty of Diponegoro University / Dr. Kariadi Hospital, Semarang

Department of Pathological Anatomy, Medical Faculty of Diponegoro University / Dr. Kariadi Hospital, Semarang

Corresponding author

Keywords: Giant condyloma acuminatum (GCA), HPV

Abstract: Giant condyloma acuminatum (GCA) is a large condyloma caused by Human papillomavirus (HPV) infection

mostly type 6 and 11, that is locally invasive and does not metastasize. Homosexual is at risk for HIV infection

and acquiring condyloma acuminatum with 53% of prevalence rate. Currently, there is no gold standard in

managing the GCA case. A 20-year-old man presented with a single wart on the perianal area for four months

previously. He had a past unprotected sexual history and multiple male partners. Physical examination

revealed a cauliflower-like verrucous tumor on the perianal area, 8 x 6 x 3 cm in size. The anti-HIV screening

was reactive. The histopathological examination showed hyperplastic stratified keratinized squamous

epithelium with papillomatous growth, acanthosis and koilocytosis, supported the diagnosis of condyloma

acuminatum. Due to the size of the tumor, the location of the tumor, and the patient's immune status; the

patient was treated with surgical excision combined with ARV therapy (tenofovir, lamivudine, efavirenz).

The third-month post-surgery evaluation showed no sign of recurrence. Surgical excision and ARV therapy

in perianal GCA patient with HIV yielded a satisfactory result. Regular evaluation after surgery is required to

identify and prevent recurrence or metastasize potential.

1 INTRODUCTION

Giant condyloma acuminatum (GCA), also known as

Buschke-Lowenstein tumor (BLT) is a large

condyloma of the anogenital region caused by HPV

infection primarily type 6 and 11, that is locally

invasive and does not metastasize.

Immunosuppressive condition, especially in HIV

patients, are ten times susceptible to condyloma

acuminatum (Indriatmi et al, 2018).

HIV-positive

men who have sex with men (MSM) have a higher

risk to acquire condyloma acuminatum, with the

prevalence rate of 53%. (Heukelom,2016) GCA has

a risk for transformation into an aggressive squamous

cell carcinoma (Kose et al, 2016).

Therapeutic option for this condition is various,

such as topical therapy, surgery, and systemic therapy

(Murtiastutik et al, 2008). Currently, there is no gold

standard in managing the GCA case (Mistrangelo et

al, 2018). Recurrences after therapy often occur. A

study found that condyloma acuminatum relapsed as

much as 12,9% on HIV-infected patients, compared

to 9,3% on non-HIV-infected patients (Indriatmi et al,

2018).

This case report aims to report a case of perianal

giant condyloma acuminatum with HIV, which was

treated with excisional surgery and anti-retroviral

drugs (ARV).

2 CASE

The patient was an unmarried, 20-year-old male, of

Javanese race (Indonesian nationality), who came to

Dermatovenereology Clinic at Dr. Kariadi General

Hospital Semarang with a perianal wart since four

months previously. Initially, the size was as small as

a corn kernel; eventually, it grew bigger; it was not

painful or itchy and did not easily bleed. The patient

also felt uncomfortable when sitting. His wart has not

been treated, and it was his first time experiencing

this kind of condition. According to his sexual

history, he had anogenital sexual intercourse with

Aldikha, I., Kusumaningsih, R., Budiastuti, A., Muslimin, . and Astuti, M.

Perianal Giant Condyloma Acuminatum with HIV Treated with Surgical Excision.

DOI: 10.5220/0009989403750379

In Proceedings of the 2nd International Conference on Tropical Medicine and Infectious Disease (ICTROMI 2019), pages 375-379

ISBN: 978-989-758-469-5

 2020 by SCITEPRESS – Science and Technology Publications, Lda. All rights reser ved

375

multiple male partners about a year before these

symptoms appeared. He did not use condoms during

intercourse. There was no history of a genital wound,

receiving a blood transfusion, or using injected

narcotic drugs. There was no family history of a

similar condition. The patient was unemployed.

Health services cost was covered by BPJS (national

health coverage insurance). The socioeconomic status

appeared to be below average.

On physical examination, the patient was fully

conscious but experiencing mild pain. He had body

height of 164 centimeters and the bodyweight of 57

kilograms, blood pressure was 110/70 mmHg, heart

rate 84 times/minute, respiratory rate 20 times/minute

and the axillary temperature was 36,6°C. Upon

perianal examination, we found a cauliflower-like

tumor with a size of 8 x 6 x 3 cm, with verrucous

surface and flesh-like color.

Laboratory examination revealed reactive Anti-

HIV screening test with CD4 amount of 220

cells/mm

, 16,1 g/dL hemoglobin, and all other blood

tests were within average values. On rectoscope

examination, the intrarectal mucosa was reddish and

no mass found. Histopathology test showed

hyperplastic stratified keratinized squamous

epithelium with papillomatous growth, acanthosis,

koilocytosis; dermis consisted of hyperemic fibrous

connective tissue along with scattered lymphocytes,

histiocytes, and PMN leucocytes; there were no signs

of malignancy. The histopathology result was

suggestive of condyloma acuminatum.

The diagnosis of this patient was perianal giant

condyloma acuminatum with HIV co-infection. The

patient was treated with excisional surgery 1 cm

around the border of the lesion and given oral anti-

retroviral (ARV) therapy consisted of efavirenz 600

mg, lamivudine 300 mg, and tenofovir disoproxil

fumarate 300 mg. Post-operative therapy for this

patient was tranexamic acid 500 mg injection three

times daily and ketorolac 30 mg injection three times

daily. The post-surgery wound healed well. The

patient was discharged from the hospital with an

excellent general condition and no signs of

hemorrhage.

On the third month of evaluation, there were no

complaints and signs of recurrences. We suggested

him to do another hospital visit at six months after

surgery or if the lesion reappeared.

3 DISCUSSION

Classification and nomenclature of broad and

extensive condyloma acuminatum remain

controversial. Some authors argue that the

classification of GCA applies if the size is more than

2,5 cm.

GCA is a sexually transmitted disease that is

presumably caused by HPV infection, mostly HPV

type 6 and 11. HPV type 6 and 11 were found in 66%

and 33% of the cases of GCA. (Kose et al, 2016). The

characteristics of GCA are as follows: slow-growing

lesion, locally invasive, and a verrucous surface that

cannot spontaneously heal..(Kim et al, 2018)

The patient was a 20-year-old male, with

unprotected sexual history and had multiple male

partners. From the literature, we found that the

incidence of GCA was 0,1%, and a male was more

susceptible to GCA than women (2,3:1).(Kim et al,

2018) The mean age at presentation is 44 years old

(Kauffman et al,2018) Other possible risk factors are

smoking, multiple sex partners, anaerobic infections,

local chronic inflammation, and immune

deficiency.(Diani et al,2015) The patient was a

homosexual which increases his susceptibility to

acquiring HIV infection and condyloma acuminatum,

even at younger ages. The most common presenting

signs of GCA are perianal mass (47%), pain (32%),

perianal abscess or fistula (32%) and bleeding (18%).

Pruritus, difficulty in walking and defecation have

also been reported.

This patient also reported

discomfort when sitting, but without any pain.

The diagnosis of GCA can be made based on

clinical manifestations. Upon physical examination,

we found a cauliflower-like perianal tumor with a size

of 8 x 6 x 3 cm, with verrucous surface and flesh-like

color. From the literature, we found that giant

condyloma acuminatum could manifest as a large,

exophytic mass with cauliflower-like shape and

irregular surface.(Guttadauro et al,2015)

GCA is

commonly seen in the anogenital region.(Akdag et

al,2018)

GCA, unlike simple condyloma, it is locally

aggressive and destructive. (Kose et al, 2016).

In this

case, the lesion initially appeared four months ago,

and the size increased gradually until it reached the

current size. The quick progressivity of GCA might

be related to the immunosuppressed state of the

patient (CD4 levels of 220 cells/mm

), that

significantly affects the process of diminishing HPV

infections on the patient. HPV infections on GCA can

only be ascertained by the finding of HPV DNA using

polymerase chain reaction (PCR) method or Hybrid

Capture 2 (HC2) test. The examination using 3 to 5

percent of acetic acid was not performed as it was

prone to false-positive. (Indriatmi et al, 2018).

A biopsy could potentially be conducted if the

clinical findings were uncertain, such as cases in

immunocompromised patients, condyloma

acuminatum that has been unsatisfactorily treated in

ICTROMI 2019 - The 2nd International Conference on Tropical Medicine and Infectious Disease

376

the past, cases of pigmented warts, warts with

ulcerations and to exclude the possibility of

malignancies. (Indriatmi et al, 2018). Upon

histopathology examination, we found stratified

keratinized squamous epithelium with papillomatous

growth, acanthosis, and koilocytosis. The dermis

consisted of fibrous connective tissue that was

hyperemic, along with scattered lymphocytes,

histiocytes, and PMN leucocytes. There were no signs

of malignancy found within the lesions. This finding

is consistent with the literature, where

histopathological findings on condyloma

acuminatum are characterized by acanthosis and

papillomatosis on Malpighi layer, thickening, and

elongation of rete ridges, with parakeratosis on the

cornified layer. On stratum corneum, we can find

mitosis, nucleus koilocytosis, and mononuclear

inflammatory cells that infiltrated into the dermis.

The histopathology appearance of GCA is similar to

the normal condyloma acuminatum, but it has to be

distinguished from squamous cell carcinoma. We can

differentiate this condition from squamous cell

carcinoma with the aid of histopathological findings

because we did not find signs of malignancy (such as

infiltration of basal membranes, a vast amount of

mitosis, invasion of blood vessels and metastatic

lymphatic lesions) in this patient. (Murtiastutik et al,

2008).

Untreated GCA can be locally very destructive,

extending into the pelvic organs and bony structure,

causing secondary infections, bleeding and its

complication.(Kauffman et al,2018)

Giant condyloma acuminatum can be treated

using topical therapeutic modality (podophyllin,

fluorouracil, or radiotherapy), surgery (cryotherapy,

laser surgery, electrosurgery or excisional

surgery), and systemic therapeutic modalities such as

chemotherapy, immunotherapy or aminolevulinate

acid. (Murtiastutik et al, 2008).

Because there is no

gold standard in managing GCA cases, the chosen

treatment for GCA is determined by size, amount,

location of the lesion, patient preference, cost, side

effects and the experience of the attending doctor.

(Mistrangelo et al, 2018)

The patient was treated with excisional surgery 1

cm from the margin of the lesion using a scalpel and

then continued with step-by-step cauterization from

perianal region to the inner mucosa of the rectum

(below the dentate line). According to the literature,

surgery was found to be the primary therapeutic

modality for GCA with a success rate of 63 to 91%,

even after recurrence.(Bessi et al, 2019) Although the

post-surgery recurrence rate is still at 50-60%, the

surgical method still has the lowest recurrence risk

compared to any other therapeutic modality of this

condition. On several cases of GCA treated with

massive excisional surgery, there were no recurrences

after a notable period of observation. Excisional

surgery with 1-cm disease-free margins seems to

guarantee the lowest rate of recurrence.(Guttadauro et

al,2015)

The application of topical therapy with podofilin

or fluorouracil is no indication for this patient.

Podofilin or fluorouracil has a poor outcome in GCA.

(Kose et al, 2016). Systemic therapies, although

possible, actually were rarely used for treating

patients with GCA. This was one of the reasons that

encouraged us to choose excisional surgery to treat

this patient.

The patient also got tranexamic acid 500 mg

injections three times a day and ketorolac 30 mg three

times a day by intravenous route as the post-operative

therapy. Post-surgery wound healed well during the

hospital stay. We discharged the patient on the fifth-

day post-surgery, with the good general condition and

without any signs of hemorrhage. We suggested the

patient visit the hospital one week after the surgery

for routine evaluation, or if the lesion reappeared.

Recurrence is a big problem with giant

condyloma, particularly in the immunocompromised

patient. The estimate of recurrence rate is 66%.

(Atkinson et al,2014) The third-month post-surgery

evaluation in this patient showed no complaint and

recurrence sign. We then suggest the patient do re-

evaluation in the sixth months after surgery.

According to the literature, some authors recommend

to see patient with a history giant condyloma every

six months in the first two years after surgery and then

annually. The average time of recurrence is

approximately ten months. (Atkinson et al,2014)

Another literature stated that recurrence of the lesion

usually happens within the first three months after

therapy. (Murtiastutik et al, 2008).

The prognosis for this patient are as follow: quo

ad vitam and quo ad sanam are dubia ad malam. This

is caused by the inability of the immune system to

prevent the entry of pathogens due to the ongoing

HIV infection. Not only this will aggravate the

current STD condition or make the STD resistant to

the therapy, but the patient might potentially get

infected with another pathogen that might risk the

patient’s life. The patient had quo ad cosmeticam

prognosis of dubia ad bonam because the excisional

surgery can remove the existing lesions, and the risk

of scarring is quite low.

Perianal Giant Condyloma Acuminatum with HIV Treated with Surgical Excision

377

Figure 1. Results of physical and histopathology examination. A & B. Physical examination on August 23

, 2018 at the

Dermato-venereology Clinic, Dr. Kariadi General Hospital Semarang; C. hyperplastic stratified keratinized squamous

epithelium with papillomatous growth [Hematoxylin & eosin (H&E), 40x]; D. acanthosis (H&E, 40x); E. koilocytosis (H&E,

400x); F. dermis consisted of inflammatory cells (H&E, 100x).

Figure 2. The patients' condition three months after surgery on January 29

, 2019, at the Dermatovenereology Clinic, Dr.

Kariadi General Hospital Semarang.

4 CONCLUSION

Surgical excision and ARV therapy in perianal GCA

patient with HIV yielded a satisfactory result. The

prognosis of the patient, including quo ad vitam and

quo ad sanam are dubia ad malam, but quo ad

cosmeticam is dubia ad bonam. Regular evaluation

after surgery is required to identify and prevent

recurrence or metastasize potential.

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